Treatment Non-Adherence Bias in Clinical Machine Learning: A Real-World Study on Hypertension Medication

Machine learning systems trained on electronic health records (EHRs) increasingly guide treatment decisions, but their reliability depends on the critical assumption that patients follow the prescribed treatments recorded in EHRs. Using EHR data from 3,623 hypertension patients, we investigate how treatment non-adherence introduces implicit bias that can fundamentally distort both causal inference and predictive modeling. By extracting patient adherence information from clinical notes using a large language model, we identify 786 patients (21.7%) with medication non-adherence. We further uncover key demographic and clinical factors associated with non-adherence, as well as patient-reported reasons including side effects and difficulties obtaining refills. Our findings demonstrate that this implicit bias can not only reverse estimated treatment effects, but also degrade model performance by up to 5% while disproportionately affecting vulnerable populations by exacerbating disparities in decision outcomes and model error rates. This highlights the importance of accounting for treatment non-adherence in developing responsible and equitable clinical machine learning systems.

A Learning Based Hypothesis Test for Harmful Covariate Shift

The ability to quickly and accurately identify covariate shift at test time is a critical and often overlooked component of safe machine learning systems deployed in high-risk domains. While methods exist for detecting when predictions should not be made on out-of-distribution test examples, identifying distributional level differences between training and test time can help determine when a model should be removed from the deployment setting and retrained. In this work, we define harmful covariate shift (HCS) as a change in distribution that may weaken the generalization of a predictive model. To detect HCS, we use the discordance between an ensemble of classifiers trained to agree on training data and disagree on test data. We derive a loss function for training this ensemble and show that the disagreement rate and entropy represent powerful discriminative statistics for HCS. Empirically, we demonstrate the ability of our method to detect harmful covariate shift with statistical certainty on a variety of high-dimensional datasets. Across numerous domains and modalities, we show state-of-the-art performance compared to existing methods, particularly when the number of observed test samples is small.